Accepted for/Published in: JMIR Public Health and Surveillance
Date Submitted: Dec 2, 2025
Date Accepted: Mar 7, 2026
Moderating Role of Condom-use Inertia on the Association Between Status Quo Bias and PrEP Resistance Intention Among Chinese Men Who Have Sex With Men: Cross-Sectional Study
ABSTRACT
Background:
While prior studies have explored structural and individual-level barriers to pre-exposure prophylaxis (PrEP) willingness or adoption, little is known about the psychological mechanisms underlying resistance to PrEP, particularly among high-risk groups. The status quo bias theory provides a theoretical framework for understanding why individuals resist adopting new health technologies despite their potential benefits.
Objective:
The objective of this study was to investigate the association between status quo bias and PrEP resistance intention among men who have sex with men (MSM) in China and to examine the moderating role of condom-use inertia in these associations.
Methods:
We conducted a cross-sectional online survey among 1122 MSM in China from November 2024 to February 2025. We developed and validated a comprehensive multi-item scale to measure the key constructs. The psychometric evaluation included Cronbach's α for internal consistency and confirmatory factor analysis (CFA) for construct validity, which confirmed the reliability and structural validity of the measures for PrEP resistance intention, transition costs, social norms, and condom-use inertia. We performed the hierarchical linear regression analysis to examine the main associations and the moderating effects of condom-use inertia.
Results:
A total of 1022 MSM were included in the final analysis (mean age 29.6 years); the majority identified as homosexual (767/1022, 75.1%) and were unmarried (896/1022, 87.7%). Confirmatory factor analysis demonstrated acceptable model fit (root mean square error of approximation [RMSEA]=0.074; comparative fit index [CFI]=0.947). Internal consistency was robust for all constructs (Cronbach α >.80). Regression analyses revealed that transition costs were positively associated with PrEP resistance intention (β=.26, 95% CI 0.17-0.35; P<.001), while social norms were negatively associated (β=–.19, 95% CI –0.27 to –0.12; P<.001). Condom-use inertia significantly moderated both associations, amplifying the positive relationship between transition costs and resistance (β=.04, 95% CI 0.01-0.09; P=.03) and enhancing the negative association of social norms (β=–.05, 95% CI –0.09 to 0.00; P=.04).
Conclusions:
This study highlights status quo bias as a key psychological barrier to PrEP adoption among Chinese MSM. By uncovering the moderating role of condom-use inertia, our findings highlight the need for behaviorally informed interventions that address the cognitive friction associated with habit change. Integrating behavioral economics into intervention design, such as leveraging social norms to penetrate habitual filters, could help reduce resistance and improve PrEP uptake through targeted nudge approaches. Clinical Trial: NA
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